Work requirements could transform Medicaid and food aid under US budget bill

The U.S. social safety net would be jolted if the budget bill backed by President Donald Trump and passed Thursday by the House of Representatives becomes law.

It would require many low-income adults to work to receive Medicaid health insurance coverage and more to work to get food assistance, require hospitals to verify the citizenship status of patients, and cut funding for services like birth control to the nation's biggest abortion provider.

Supporters of the bill say the moves will save money, root out waste and encourage personal responsibility.

A preliminary estimate from the nonpartisan Congressional Budget Office said the proposals would reduce the number of people with health care by 8.6 million over the decade.

The measure, which also includes tax cuts, passed the House by one vote and could have provisions reworked again as it heads to the Senate.

Here's a look at the potential impact.

Starting next year, many able-bodied Medicaid enrollees will be required to show that they work in exchange for the health insurance coverage.

While about 92% of people enrolled now meet the requirement, roughly 5 million would likely lose their coverage, according to previous estimates of an earlier version of the bill provided by the Congressional Budget Office.

Increased eligibility checks and red tape related to work requirements may result in some people wrongly getting booted off, said Eduardo Conrado, the president of Ascension, a health care system that operates hospitals across 10 states.

That could spell trouble for rural hospitals, in particular, who will see their small pool of patients go from paying for their emergency care with Medicaid coverage to not paying anything at all. Hospitals could have to eat their costs.

“Adding work requirements is not just a policy change, it’s a shift away from the purpose of the program,” Conrado said of the rule.

Only Arkansas has had a work requirement that kicks people off for noncompliance. More than 18,000 lost coverage after it kicked in in 2018, and the programs was later blocked by federal courts.

Joan Alker, executive director of Georgetown University’s Center for Children and Families, said work requirements do not result in more people having jobs — but in fewer people having health insurance.

“If you lose your job going forward, good luck to you,” she said. “There is a good chance you’re going to be uninsured because of this bill.”

The Supplemental Nutrition Assistance Program, formerly known as food stamps, already requires work for some of its roughly 42 million recipients. Adults ages 18-54 who are physically and mentally able and don’t have dependents must work, volunteer or participate in training programs for at least 80 hours a month, or else be limited to just three months of benefits in a three-year period.

The legislation passed by the House would raise the work requirement to age 65 and also extend it to parents without children younger than age 7. The bill also would limit the ability to waive work requirements in areas with unemployment rates significantly above the national average.

The combination of those changes could put 6 million adults at risk of losing SNAP benefits, according to the liberal-leaning Center on Budget and Policy Priorities.

Like work requirements for Medicaid, those for SNAP tend to cause a decrease in participation without increasing employment, according to an April report by the Brookings Institution’s Hamilton Project.

Under the bill, the federal government would punish states that use their own state dollars to provide Medicaid-covered services to immigrants lacking legal status or to provide subsidies to help them buy health insurance.

Some states that provide that sort of coverage extend it only to children.

Those states would see federal funding for the Medicaid expansion population — typically low-income adults — drop from 90% to 80%.

That could mean states pull back that Medicaid coverage to avoid the federal penalty.

“If that penalty of 10% is imposed, we would expect that states will have to drop that coverage,” said Georgetown's Alker.

KFF said the provision could affect 14 states and Washington, D.C., that cover children regardless of their immigration status.

This month the Democratic governor of one of them — California's Gavin Newsom — announced a plan to freeze new enrollments in state-funded health care for immigrants who do not have legal status as a budget-balancing measure.

Planned Parenthood says a provision barring it from receiving Medicaid funds could lead to about one-third of its health centers closing.

The group said about 200 centers are at risk — most of them in states where abortion is legal. In those states, the number of Planned Parenthood centers could be cut in half.

Planned Parenthood, the nation’s largest abortion provider, also offers other health services, including birth control and cancer screening.

Federal money was already barred from paying for abortion, but state Medicaid funds in some states now cover it.

“We’re in a fight for survival — not just for Planned Parenthood, but for the ability of everyone to get high-quality, non-judgmental health care,” Planned Parenthood President and CEO Alexis McGill Johnson said in a statement.

Susan B. Anthony Pro-Life America celebrated the provision, saying “Congress took a big step toward stopping taxpayer funding of the Big Abortion industry.”

Medicaid would stop covering gender-affirming care for people of all ages in 2027 under a provision added in the hours before the bill passed.

Further, coverage of the treatments could not be required on insurance plans sold through the exchanges under the Affordable Care Act.

Trump has targeted transgender people, who make up around 1% of the U.S. population, since returning to office, including declaring that the U.S. won’t spend taxpayer money on gender-affirming medical care for transgender people under 19. The care includes puberty blockers, hormone therapy and surgeries.

The bill would expand that to all ages, at least when it comes to Medicaid.

States now have a mix of policies on the issue with some blocking the coverage and others requiring it.

An AP-NORC Center for Public Affairs Research poll this month found that about half of U.S. adults oppose government funding for the care for those 19 and over.

Olivia Hunt, director of federal policy for Advocates for Trans Equality called gender-affirming care “one of the most cost-effective public health strategies we've ever found.”

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Associated Press reporters Devna Bose in Jackson, Mississippi; Marc Levy in Harrisburg, Pennsylvania; and Amanda Seitz in Washington contributed to this article.